Opioid analgesics are extremely effective medications for the management of acute pain, especially pain associated with injuries or surgery. They are also extremely effective for managing cancer pain and in palliative care situations. Their use for chronic non-cancer pain remains associated with clinical controversy and, at times, with adverse outcomes. Physicians should receive more education about the problems of prescription drug diversion, misuse, addiction and overdose deaths, and steps physicians can and should take in the course of their regular daily practice to mitigate the risks of opioid prescribing and minimize the incidence of prescription drug diversion, misuse, addiction and overdose deaths.

The Wisconsin Medical Society supports the following principles:

Physiciansa should include opioid analgesics as part of evidence-based treatment plans for patients, to reduce discomfort and to maximize functioning, when their use is medically necessary.

Patients should have access to these medications when they are medically necessary so that they receive compassionate and comprehensive care when they have painful health conditions.

Physicians should make decisions about prescribing opioids with understanding of current policies and clinical guidelines promulgated by the Wisconsin Medical Examining Board, and should be aware of and review other guidelines from the Centers for Disease Control and Prevention, Federation of State Medical Boards, Food and Drug Administration, national medical specialty societies and other entities addressing the issue of safe and responsible opioid prescribing. Neither medical practice acts nor the credentialing procedures of health plans, hospitals or clinics, should provide for limitations on or sanctions against physicians based solely on the dosages of opioid analgesics prescribed or the number of pain patients they see in their practices.

Physicians should be more aware of the various indications for opioid analgesics and therapeutic alternatives based on the type of pain a patient may present with, including non-opioid pharmacotherapies for neuropathic pain and for myofascial pain syndromes.

Physicians should be more aware of both addiction and physical dependence (withdrawal) as among the potential adverse outcomes from the long-term prescribing of opioid analgesics. Any physician who initiates a care plan involving chronic opioid analgesic therapy should be knowledgeable and comfortable in methods for safe discontinuation of opioids in tolerant individuals and for opioid withdrawal management. Physicians should encourage nursing staff in hospitals and clinics where they practice to utilize standardized rating scales for assessing the severity of opioid withdrawal.

Physicians should not be limited to prescribing only abuse-deterrent or abuse-resistant medications as they become clinically available, but rather should have flexibility in prescribing practices, increased opportunities for education on the potential benefits of abuse-deterrent or abuse-resistant medications, and increased education about the importance of clear communication with patients on the risks and safe use of such medications.

Physicians should be more aware of the phenomena of prescription drug diversion, misuse and overdose deaths, and should be mindful of the potential for diversion of drug supplies that originate with a legitimate prescription written for appropriate indications. Physicians should receive education on the theory, practice and utility of office-based and Emergency Department Screening and Brief Intervention processes to identify potential cases of substance use disorder. Risk assessment prior to the initiation of opioid therapy should become a regular part of medical and surgical practice.

Physicians should receive education on how physicians can make optimal use of the Wisconsin Prescription Drug Monitoring Program.

Physicians who prescribe controlled substances should accept the responsibilities they have to educate the patient at the time of issuing a prescription about benefits, risks and alternatives, and about safe drug storage and disposal practices that should be adhered to by patients.

Physicians should support initiatives to establish statewide standards and methods for the effective disposal of consumer medications in all care programs (including home health care hospice programs) and facilities (including nursing homes and residential hospice programs) and which comply with state and federal waste management laws.

Physicians should become active in their communities, volunteering their time to become community problem-solvers regarding health topics relevant to their communities and the emerging epidemics of prescription drug abuse and opioid overdose deaths.

Physicians should work with schools and school boards to optimize the health education students receive regarding substance use disorders and related conditions, including facts regarding the epidemiology of overdose deaths among youth in Wisconsin.

Physicians should work with their communities to support the implementation of evidence-based substance abuse prevention programs and practices, such as those in the National Registry of
Evidence-based Programs and Practices developed by the Substance Abuse and Mental Health Services Administration (http://www.nrepp.samhsa.gov/01_landing.aspx).

Physicians should work with citizen coalitions in their communities regarding safe drug storage and disposal with respect to controlled substances such as opioid analgesics.

aThis Statement of Principles was prepared by the Wisconsin Medical Society for the benefit of the physician members of the Society and the patients those physicians serve. However, these Principles apply to all licensed independent practitioners with prescribing authority. While this Statement does not use the term “prescribers,” in most cases where the term “physician” appears, the Principles could/should be generalized to reference all prescribers of opioid analgesics. (HOD, 0416)